Transcript Case 3
AJCC Staging Moments AJCC TNM Staging 7th Edition Rectal Case #3 Contributors: J. Milburn Jessup, MD Cancer Diagnosis Program, DCTD, NCI, Rockville, Maryland Mary Kay Washington, MD Vanderbilt University Medical Center, Nashville, Tennessee Jose Guillem, MD Memorial Sloan-Kettering Cancer Center, New York, New York Frederick L. Greene, MD Carolinas Medical Center, Charlotte, North Carolina Rectal Case # 3 Presentation of New Case • Newly diagnosed rectal cancer patient • Presentation at Cancer Conference for treatment recommendations and clinical staging Rectal Case # 3 History & Physical • 51 yr old male who presented with diarrhea and abdominal pain • No family history of colon or rectal cancer Rectal Case # 3 Imaging & Endoscopy Results • Colonoscopy-single large circumferential fungating mass in rectum 2 to 5cm from anus Retroflexed endoscope with rectal tumor used with permission Julio Murra-Saca, MD El Savador Atlas of Gastrointestinal Video Endoscopy Rectal Case # 3 Diagnostic Procedure • Procedure – Biopsy rectal mass • Pathology Report – Adenocarcinoma, invasive – Grade 2 • CEA: 4.3 Rectal Case # 3 Imaging Results • Endorectal ultrasound – Invasion into peri-rectal fat • CT chest/abd/pelvis – – – – used with permission Julio Murra-Saca, MD El Savador Atlas of Gastrointestinal Video Endoscopy Thickening in rectal and perirectal soft tissue 1.2cm peri-iliac node mesenteric node 1.7cm perirectal lymphadenopathy No liver metastases Rectal Case # 3 Clinical Staging • Clinical staging – Uses information from the physical exam, imaging, and diagnostic biopsy • Purpose – Select appropriate treatment – Estimate prognosis Rectal Case # 3 Clinical Staging • Synopsis- patient with rectal mass and perirectal tissue involvement, and clinically involved nodes • What is the clinical stage? – – – – T____ N____ M____ Stage Group______ Rectal Case # 3 Clinical Staging • Clinical Stage correct answer – – – – T3 N1 M0 Stage Group IIIB • Based on stage, treatment is selected • Review NCCN treatment guidelines for this stage Rectal Case # 3 Clinical Staging • Rationale for staging choices – T3 for into non-peritonealized pericolic or perirectal tissues – N1 because nodes were clinically positive on imaging – M0 because there was nothing to suggest distant metastases; if there was, appropriate tests would be performed before developing a treatment plan Prognostic Factors Clinically Significant • Applicable to this case – CEA: 4.3 • There are no prognostic factors required for staging Rectal Case # 3 Surgery & Findings • Patient received neoadjuvant Rx with chemotherapy and radiation therapy • Procedure – Transabdominal resection • Operative findings – Colo-anal anastomosis performed with 2 cm margin Rectal Case # 3 Pathology Results • • • • • • • • • Residual adenocarcinoma, rectum Tumor size - 3cm Grade 3, poorly differentiated Through muscle wall into pericolonic soft tissue Margins negative Circumferential resection margin clear by 8mm Mets 3/12 regional nodes No perineural or lymph-vascular invasion Tumor deposits were not identified Rectal Case # 3 Pathologic Staging • Pathologic staging – Uses information from the clinical staging supplemented or modified by information from surgery and the pathology report – yp is assessment at conclusion of therapy • Purpose – Additional precise data for estimating prognosis – Calculating end results (survival data) – yp – extent of response to therapy Rectal Case # 3 Pathologic Staging • Synopsis- patient with rectal ca into pericolonic soft tissue, and positive nodes after neoadjuvant chemo and RT • What is the pathologic stage? (remember, clinical M may be used in pathologic staging) – – – – T____ N____ M____ Stage Group______ Rectal Case # 3 Pathologic Staging • Pathologic Stage correct answer – – – – ypT3 ypN1 cM0 ypStage Group IIIB • Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected Rectal Case # 3 Pathologic Staging • Rationale for staging choices – ypT3 for into non-peritonealized pericolic or perirectal tissues after neoadjuvant chemo/RT – ypN1 because nodes were positive on exam after neoadjuvant chemo/RT – cM0 - classified by M status prior to therapy – y prefix used to show stage during or following neoadjuvant therapy Prognostic Factors Clinically Significant • Applicable to this case – CEA: 4.3 – Circumferential resection margin: 8mm – Tumor deposits: no – Perineural invasion: no • There are no prognostic factors required for staging AJCC Cancer Staging Atlas T3 into non-peritonealized pericolic or perirectal tissues (adventitia) Rectal Case # 3 Recap of Staging • Summary of correct answers – Clinical stage T3 N1 M0 Stage Group IIIB – Pathologic stage ypT3 ypN1 cM0 ypStage Group IIIB • The staging classifications have a different purpose and therefore can be different. Do not go back and change the clinical staging based on pathologic staging information. Staging Moments Summary • Review site-specific information if needed • Clinical Staging – Based on information before treatment – Used to select treatment options • y Pathologic Staging – Based on clinical data PLUS surgery and pathology report information after neoadjuvant therapy – Assesses response to treatment – Used to evaluate end-results (survival)